Public Act 099-0111
HB2788 EnrolledLRB099 08001 MLM 28141 b

    AN ACT concerning insurance.
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
    Section 5. The Managed Care Reform and Patient Rights Act
is amended by changing Sections 80 and 85 as follows:
    (215 ILCS 134/80)
    Sec. 80. Quality assessment program.
    (a) A health care plan shall develop and implement a
quality assessment and improvement strategy designed to
identify and evaluate accessibility, continuity, and quality
of care. The health care plan shall have:
        (1) an ongoing, written, internal quality assessment
        (2) specific written guidelines for monitoring and
    evaluating the quality and appropriateness of care and
    services provided to enrollees requiring the health care
    plan to assess:
            (A) the accessibility to health care providers;
            (B) appropriateness of utilization;
            (C) concerns identified by the health care plan's
        medical or administrative staff and enrollees; and
            (D) other aspects of care and service directly
        related to the improvement of quality of care;
        (3) a procedure for remedial action to correct quality
    problems that have been verified in accordance with the
    written plan's methodology and criteria, including written
    procedures for taking appropriate corrective action;
        (4) follow-up measures implemented to evaluate the
    effectiveness of the action plan.
    (b) The health care plan shall establish a committee that
oversees the quality assessment and improvement strategy which
includes physician and enrollee participation.
    (c) Reports on quality assessment and improvement
activities shall be made to the governing body of the health
care plan not less than quarterly.
    (d) The health care plan shall make available its written
description of the quality assessment program to the Department
of Public Health.
    (e) With the exception of subsection (d), the Department of
Public Health shall accept evidence of accreditation with
regard to the health care network quality management and
performance improvement standards of:
        (1) the National Commission on Quality Assurance
        (2) the American Accreditation Healthcare Commission
        (3) the Joint Commission on Accreditation of
    Healthcare Organizations (JCAHO); or
        (4) the Accreditation Association for Ambulatory
    Health Care (AAAHC); or
        (5) (4) any other entity that the Director of Public
    Health deems has substantially similar or more stringent
    standards than provided for in this Section.
    (f) If the Department of Public Health determines that a
health care plan is not in compliance with the terms of this
Section, it shall certify the finding to the Department of
Insurance. The Department of Insurance shall subject a health
care plan to penalties, as provided in this Act, for such
(Source: P.A. 91-617, eff. 1-1-00.)
    (215 ILCS 134/85)
    Sec. 85. Utilization review program registration.
    (a) No person may conduct a utilization review program in
this State unless once every 2 years the person registers the
utilization review program with the Department and certifies
compliance with the Health Utilization Management Standards of
the American Accreditation Healthcare Commission (URAC)
sufficient to achieve American Accreditation Healthcare
Commission (URAC) accreditation or submits evidence of
accreditation by the American Accreditation Healthcare
Commission (URAC) for its Health Utilization Management
Standards. Nothing in this Act shall be construed to require a
health care plan or its subcontractors to become American
Accreditation Healthcare Commission (URAC) accredited.
    (b) In addition, the Director of the Department, in
consultation with the Director of the Department of Public
Health, may certify alternative utilization review standards
of national accreditation organizations or entities in order
for plans to comply with this Section. Any alternative
utilization review standards shall meet or exceed those
standards required under subsection (a).
    (b-5) The Department shall recognize the Accreditation
Association for Ambulatory Health Care among the list of
accreditors from which utilization organizations may receive
accreditation and qualify for reduced registration and renewal
    (c) The provisions of this Section do not apply to:
        (1) persons providing utilization review program
    services only to the federal government;
        (2) self-insured health plans under the federal
    Employee Retirement Income Security Act of 1974, however,
    this Section does apply to persons conducting a utilization
    review program on behalf of these health plans;
        (3) hospitals and medical groups performing
    utilization review activities for internal purposes unless
    the utilization review program is conducted for another
    Nothing in this Act prohibits a health care plan or other
entity from contractually requiring an entity designated in
item (3) of this subsection to adhere to the utilization review
program requirements of this Act.
    (d) This registration shall include submission of all of
the following information regarding utilization review program
        (1) The name, address, and telephone number of the
    utilization review programs.
        (2) The organization and governing structure of the
    utilization review programs.
        (3) The number of lives for which utilization review is
    conducted by each utilization review program.
        (4) Hours of operation of each utilization review
        (5) Description of the grievance process for each
    utilization review program.
        (6) Number of covered lives for which utilization
    review was conducted for the previous calendar year for
    each utilization review program.
        (7) Written policies and procedures for protecting
    confidential information according to applicable State and
    federal laws for each utilization review program.
    (e) (1) A utilization review program shall have written
procedures for assuring that patient-specific information
obtained during the process of utilization review will be:
        (A) kept confidential in accordance with applicable
    State and federal laws; and
        (B) shared only with the enrollee, the enrollee's
    designee, the enrollee's health care provider, and those
    who are authorized by law to receive the information.
    Summary data shall not be considered confidential if it
does not provide information to allow identification of
individual patients or health care providers.
        (2) Only a health care professional may make
    determinations regarding the medical necessity of health
    care services during the course of utilization review.
        (3) When making retrospective reviews, utilization
    review programs shall base reviews solely on the medical
    information available to the attending physician or
    ordering provider at the time the health care services were
        (4) When making prospective, concurrent, and
    retrospective determinations, utilization review programs
    shall collect only information that is necessary to make
    the determination and shall not routinely require health
    care providers to numerically code diagnoses or procedures
    to be considered for certification, unless required under
    State or federal Medicare or Medicaid rules or regulations,
    but may request such code if available, or routinely
    request copies of medical records of all enrollees
    reviewed. During prospective or concurrent review, copies
    of medical records shall only be required when necessary to
    verify that the health care services subject to review are
    medically necessary. In these cases, only the necessary or
    relevant sections of the medical record shall be required.
    (f) If the Department finds that a utilization review
program is not in compliance with this Section, the Department
shall issue a corrective action plan and allow a reasonable
amount of time for compliance with the plan. If the utilization
review program does not come into compliance, the Department
may issue a cease and desist order. Before issuing a cease and
desist order under this Section, the Department shall provide
the utilization review program with a written notice of the
reasons for the order and allow a reasonable amount of time to
supply additional information demonstrating compliance with
requirements of this Section and to request a hearing. The
hearing notice shall be sent by certified mail, return receipt
requested, and the hearing shall be conducted in accordance
with the Illinois Administrative Procedure Act.
    (g) A utilization review program subject to a corrective
action may continue to conduct business until a final decision
has been issued by the Department.
    (h) Any adverse determination made by a health care plan or
its subcontractors may be appealed in accordance with
subsection (f) of Section 45.
    (i) The Director may by rule establish a registration fee
for each person conducting a utilization review program. All
fees paid to and collected by the Director under this Section
shall be deposited into the Insurance Producer Administration
(Source: P.A. 91-617, eff. 7-1-00.)